Palliative care should be part of basic care, experts say

March 7, 2013
| by Hiu Chung So

Doctors may specialize soon after leaving medical school, but they all possess basic clinical skills such as the ability to suture a wound or find a vein for blood draws. If two palliative care experts have their way, all physicians would have a primer on symptom relief, too.

With the demand for palliative care rising, all clinicians should be trained in basic symptom assessment and management skills, says a NEJM perspective article. (Photo credit: Stockbyte)

Since being recognized as a subspecialty by the American Board of Medical Specialties in 2006, palliative care has grown rapidly in many health care systems, but this trend — paired with a mindset of using palliative medicine specialists to handle everything related to symptom management — can be problematic, according to Timothy E. Quill, M.D., and Amy P. Abernethy, M.D., president and president-elect of the American Academy of Hospice and Palliative Medicine.

“Although it may be theoretically optimal for palliative medicine specialists to take on all palliative aspects of care, this model has negative consequences,” they write in a perspective article in the March 6 issue of the New England Journal of Medicine. This includes an insufficient supply of providers to meet demand, especially if other physicians begin to eschew basic symptom relief and psychosocial support.

Simply put, they write: “There are nowhere near enough palliative care specialists to provide all palliative care services for every very ill patient."

To address this, Quill and Abernethy propose a care model that would encompass both primary palliative care and specialized palliative care. Primary palliative care would include palliative care skills in which all clinicians should be trained — such as basic assessment and management of pain, anxiety, depression and other symptoms. Specialized palliative care would handle more complex cases and would include addressing refractory symptoms, helping patients and their families with complicated grief, and resolving conflict about treatment methods and goals.

Concurring with the authors, Carin van Zyl, M.D., assistant clinical professor in the Department of Supportive Care Medicine at City of Hope, said this dual track model “will make better physicians of all of us rather than just redistribute the demand of palliative care; palliative medicine specialists can not only be expert providers in complicated cases but also be teachers by examples to their colleagues.”

Van Zyl, who was not a part of the perspective article, described plans at City of Hope to integrate palliative medicine specialists with oncologists, allowing them to share the same clinic space. Such integration will foster real-time collaboration and a whole-person approach to treating the patient, she said.

“As oncologists observe us manage complex physical, emotional and spiritual symptoms, we add those skills to their toolbox,” she said. “More importantly, this demonstrates the benefits of a concurrent cancer care model, showing that aggressive disease-targeted therapy and palliative medicine are not mutually exclusive.”